Antepartum

period

intrapartum
 Minimising fetal morbidity during labor is one
of the principal aims of antepartum or
intrapartum care
 • Maternal history/examination
1 • Weight gain/BP

• Fetal kick chart

2 • Intermitten fetal heart auscultation

• CTG
3 • USS/UA Doppler
 aim of preventing perinatal mortality and the
occurrence of hypoxic damage to the fetus.

 the benefit of EFM over intermittent

auscultation remains uncertain
 performed at intervals varying from every
2 hours to every 15 minutes- depending on
the circumstances

 for example, more frequently if there is

meconium staining of the amniotic fluid, or
during the second stage
 Auscultation is best performed at the end of a
contraction,

 to detect late decelerations (transient

decrease in heart rate occurring at or after
the end of a uterine contraction),

 but at this time the fetal heart is often

difficult to hear.
 A fetal heart rate above 150 beats/minute

 or below 110 beats/minute for more than a

few minutes

 Any slowing of the heart rate by more than

15 beats/minute after contractions
 low risk pregnancies, EFM offers no added
benefit over intermittent auscultation.

 revealed an increase in maternal morbidity due to

a higher incidence of caesarean sections (CS) and
operative vaginal delivery.

 The risk of a CS delivery was the greatest in low

risk pregnancies. The only significant clinical
benefit with routine use of EFM was the reduction
in the incidence of neonatal seizures.
 the detection of fetal acidemia (pH<7.15) was
better with EFM in comparison to intermittent
auscultation(97% vs37%)

 EFM group there was a greater frequency of

acidemia(9.9% vs. 4.9%) and the acidemia was
more severe.

 appear that EFM neither prevented nor did it

reduce the severity of fetal acidemia
 The majority of infant brain damage occurs
before the intrapartum period

 in the absence of an acute intrapartum event

only a small minority of fetus can potentially
suffer from intrapartum hypoxia.
 The Admission test may help to identify those
cases at risk in labour

 This involves performing a period of

continuous EFM on admission in early labour
 assess the ability of the fetus to withstand the
functional stress of uterine contractions
during early labour.

 If the cardiotocogram (CTG) is reactive, the

risk of fetal hypoxia other than due to an
acute event is low in the next few hours of
labour
 If the admission test is reactive, a gradually
developing hypoxia can be suspected by a
rising fetal heart rate on auscultation.

 Fetal acidemia is a slowly developing event

from the onset of changes in the fetal heart
rate.
 The fetus suffers from brain damage only
when exposed to prolonged and profound
hypoxia.

 In a gradually developing hypoxia, abnormal

patterns may be present for 120 to 140
minutes before fetal acidemia increases
significantly
 Heart rate
 Variability
 Acceleration
 Deceleration
 Contraction
 Fetal activity
 Ultrasound probe (FHR) and a pressure
transducer placed on the mother abdomen
 Autonomic Nervous System (ANS):

◦ Sympathetic, responsible of acceleration in the

Heart Beat

◦ parasympathetic accountable for deceleration

EFM is easy to apply and gives a reliable
recording of fetal heart rate
 The CTG trace generally shows two lines.

 The upper line is a record of the fetal heart

rate in beats per minute.

 The lower line is a recording of uterine

contractions from the toco
 The vertical scale of this trace depends on
how the transducer is picking up the
contractions so interpretation needs to be in
relation to the rest of the trace.

 The trace may also have markings on it that

are indications that the mother has felt a fetal
movement (operated by a switch given to the
mother)
 Between 110 – 150 bpm

 Depends on fetal gestation

 If between 110 and 100 it is suspicious
whereas below 100 it is pathological.

 A steep sustained decrease in rate is

indicative of fetal distress and if the cause
cannot be reversed the fetus should be
delivered
 A suspicious tachycardia is defined as being
between 150 and 170 whereas a pathological
pattern is above 170.

 Tachycardias can be indicative of fever or

fetal infection and occasionally fetal distress
(with other abnormalities).

 An epidural may also induce a tachycardia in

the fetus
 The short term variations in the baseline
should be between 10 and 15 bpm (except
during intervals of fetal sleep which should
be no longer than 60 minutes).

 Prolonged reduced variability along with

other abnormalities may be indicative of fetal
distress
 These may either be normal or pathological.

 Early decelerations occur at the same time as

uterine contractions and are usually due to
fetal head compression and therefore occur
in first and second stage labour with decent
of the head.

 They are normally perfectly benign.

 Late decelerations persist after the
contraction has finished and suggest fetal
distress.

 Variable decelerations vary in timings and

shape with respect to each other and may be
indicative of hypoxia or cord compression
 A normal CTG is a good sign

but
a poor CTG does not always suggest fetal
distress.
 "At risk" features in mothers:
 Diabetes Hypertension
 Labour before 34 weeks
 Labour after 42 weeks
 Intermittent monitoring shows:

◦ Tachycardia >150 beats/minute

◦ Bradycardia <110 beats/minute S
◦ lowing of heart beat by >15 beats/minute after
contraction
 Meconium staining of liquor
 Steer, P. BMJ 1999;318:858-861

Copyright ©1999 BMJ Publishing Group Ltd.

 During the first stage of labour about a fifth
of normal fetuses will have a fetal heart rate
pattern that is not normal

 most abnormalities reflect stress for example,

temporary cord compression or hypoxia
rather than distress.
 Steer, P. BMJ 1999;318:858-861

Copyright ©1999 BMJ Publishing Group Ltd.

 Steer, P. BMJ 1999;318:858-861

Copyright ©1999 BMJ Publishing Group Ltd.

 Although late decelerations nearly always
indicate some degree of hypoxia

 fetal reserve is variable

 the ability of the fetus to cope over a period

of time can be assessed only with serial blood
sampling to give blood gas and pH
estimation.
 Steer, P. BMJ 1999;318:858-861

Copyright ©1999 BMJ Publishing Group Ltd.

 Variable decelerations after oxytocin
stimulation
 No Caption Found

Steer, P. BMJ 1999;318:858-861

Cardiotocogram showing fetal tachycardia and
variable decelerations with maternal fever
Copyright ©1999 BMJ Publishing Group Ltd.
 Computerised analysis of fetal heart rate
patterns in labour is now almost possible, as
recent trials of such systems have been
encouraging
 Computer based teaching programmes offer
a real chance of improving the general
standard of interpretation
Thank you